INSTRUMENT CLEANING BRUSHESMANUAL CLEANING: WHY? HOW? WHAT IF?

Copyright © 2014 Key Surgical

The Risk of Dirty 1 out of every 25 hospitalized patients contracts a healthcare-associated

infection (HAI) annually in the US

HAIs affect 1.7 million patients annually

100,000 deaths/year attributed to HAIs, making them one of the top 10 causes of death in the US (more than from AIDS, breast cancer and automobile accidents combined)

HAIs account for at least $20 billion in excess healthcare costs/year

Costs attributable to HAI average $21,000/patient

25% of HAIs are due to surgical site infectionshttp://www.cdc.gov/nhsn/dataStat.html

http://aharesourcecenter.wordpress.com/tag/hospital-acquired-infections-statistics/

The Challenge of Clean

There are no standards for measuring clean How clean is clean? How clean is clean enough? How clean is safe?

Testing for clean is difficult Takes time Costs money May require re-cleaning of the device due to contamination

during the testing process

Manufacturer IFUs don’t always contain instructions for testing

BrushesThe Most Basic and Versatile Tool for Cleaning

FUN FACT

Q: What is a more hygienic tool for cleaning? Sponge Brush Washcloth

A: Brush. They are easier to clean and faster to dry.

Bacteria need three things to grow: moisture, food and temperature appropriate to the bacteria species. That means, if you deny it moisture and food, it dies. A brush 1) does not retain moisture and the surface moisture dries quickly and 2) allows a user to see the visible food. So at a minimum, rinse and dry. And whenever in doubt, throw it out!

Source: www.apartmenttherapy.com

Objectives

Discuss the different brush materials available and their characteristics

Explain antimicrobial properties of brushes

Discuss the considerations when selecting a brush

Explain the difference between disposable & reusable brushes and how to clean and disinfect them

Apply industry guidelines to all the above objectives

Discuss the risk of not following recommended practices and manufacturer’s IFU when using brushes

History of the Brush

1498: Emperor of China patented the 1st toothbrush made of hogback bristles set into a piece of bone or bamboo

1780: William Addis (England) began importing coarse boar bristles from Siberia & Northern China for quality mass-produced toothbrushes

1844: Meyer Rhein patented the 3-row toothbrush

WWI: Celluloid plastic brush handles appear because all bones were needed for soup

1932: Modern plastic toilet bowl brush was introduced

1938: Dr. West’s Miracle Tuft Toothbrush was made with nylon bristles, a new invention from DuPont

1940’s: Fuller Brush Company supplied the military with 40 million brushes for cleaning weapons

Brush Terminology

Bristles: part of the brush that does the workThree types of bristle filament (fill) material

Synthetic: man-made Natural: hair, bristle or vegetable fiber Wire: strands of metal

Handle: part of the brush that holds the bristles in placePopular handle materials include

Twisted stainless steel Molded plastic blocks Rigid/semi rigid tubing/rods Spring coil stainless steel wire

Brush Terminology

Abrasion Resistance Property which allows a material to resist wear; will resist erosion

caused by scraping, rubbing and other mechanical wear Allows the material to retain its integrity and hold its form

Bristle Bend Recovery Ability of a material to return to its original shape after deformation Determined by measuring the ability of a filament to straighten out

after bending

Photos courtesy of DuPont® Filaments

Brush Terminology

Corrosion Resistance Gradual destruction of material, usually metals, by chemical reaction Ability to fight off electrochemical oxidation attacks (rust)

Flex Fatigue/Non-Shedding Measure of a material’s resistance to splitting or breaking

Photos courtesy of DuPont® Filaments

Bristle Materials

Material Characteristics

Nylon (Synthetic)

• Toughest, most durable synthetic filament available• Non-shedding• Excellent abrasion resistance• Excellent bristle bend recovery• Very good chemical resistance; resists most acids• Best choice for abrasive, rough use as it does not scratch most

surfaces

Polypropylene (Synthetic)

• One of the most chemically resistant synthetic filament materials, especially strong acids and bases

• Does not absorb moisture so maintains stiffness when wet• Excellent resistance to fungal and bacterial growth• Flex fatigue resistance so bristles don’t splay as quickly• Good abrasion resistance• Sheds dirt easily• Inert to most solvents, oils and chemicals

Bristle Materials

Material Characteristics

Brass • Softest metal fiber available• Used for light to medium cleaning of scratch susceptible surfaces• High degree of abrasion for cleaning heavily soiled equipment

without damaging the surface• Corrosion resistant• Poor bristle recovery• Will not generate sparks making it suitable for use in static

reduction applications• Same gage filament as soft stainless steel (.003”)

Stainless Steel • Highly resistant to corrosion, heat and chemicals• Excellent bend recovery• Provides high degree of abrasion and wear resistance• Not to be used on insulated or coated instruments• Excellent for more aggressive cleaning (i.e. serrations, box locks)• Also available in a softer stainless version (.003” vs .008”

filament)

Note: Use stainless steel brushes instead of carbon steel wire, which is a stronger, more aggressive bristle that can damage instruments

FUN FACT

Q: What is a common use for wire bristle brushes?

A: Cleaning the teeth of large animals such as pigs and crocodiles.

Antimicrobial

What is an antimicrobial? A substance that kills or inhibits the growth of microorganisms such

as bacteria, fungi or protozoans Can be antibiotics or synthetically formed compounds

What are antimicrobial bristles? Bristles, usually nylon, that have been either coated or inbuilt with

an inorganic antimicrobial material Coated: antimicrobial material is applied

to the surface area of the bristle filament Inbuilt: antimicrobial material is infused

in the bristle filament during the

manufacturing of the filament

Antimicrobial

What is the benefit of antimicrobial bristles? Providing superior infection control properties by preventing the

growth of bacteria, mold and yeast on the surface of the bristles

How does this affect the brush bristles? There is no impact to the fit, form or function of the brush or its

cleaning capabilities The resistance of bacterial growth slows the breakdown of the bristle

material, which may prolong the useful life of the bristles

Does this mean antimicrobial brushes clean better? NO – they do not improve the cleaning properties nor do they prevent

specimen growth on the surfaces being cleaned

Brush SelectionOne Size Does Not Fit All

Only brushes designated or designed for use in cleaning of instruments & devices should be used

AST Recommended Standards of Practice for the Decontamination of Surgical Instruments, pg. 5

ANSI/AAMI ST79:2010, section 7.5.3.2, pg. 57

Instruments with lumens should be brushed using a brush that is of the correct size for the lumen... Brushes should be … the appropriate size and bristle type.

ANSI/AAMI ST79:2010, section 7.5.6, pg. 59

Use cleaning brushes appropriate for the size of the endoscope channel or port CDC Guideline for Disinfection and Sterilization in Healthcare Facilities,

2008, pg. 86

Brush SelectionOne Size Does Not Fit All

Proper brush selection is critical to

thorough & effective cleaning!

Key to efficiency is maximum bristle tip contact to surface

and the proper type of bristle for the surface being cleaned

BRUSH SELECTIONONE SIZE DOES NOT FIT ALL

Brush SelectionOne Size Does Not Fit All

Feature Consideration RiskBrush Diameter Too large

Brush diameter should be no more than 1/8” larger than the channel

Too smallBrush diameter should be no smaller than the actual channel diameter

• Bristles lay against walls of the lumen and don’t produce enough friction for scrubbing

• Brush becomes stuck inside channel, possibly damaging device and/or brush

• Bristles don’t touch the walls of the lumen, providing no scrubbing action necessary for cleaning

Brush Length Too shortBrush should be about 2” longer than the channel being cleaned

• Doesn’t clean entire length of channel

• Unable to push dirt through open end

Brush SelectionOne Size Does Not Fit All

Feature Consideration RiskBrush Handle Looped end

Loops at the end prevent the brush from completely entering the lumen and getting stuck

Loops allow brushes to be hung for drying and storage

Non-Looped endNon-looped handles allow the brush to be pulled through the lumen

Handle material

• Looped ends prevent the brush from reaching the full length of the lumen

• Improper storage of brushes between uses can damage the bristles and promote the growth of biofilms

• Brush can become lodged inside of lumen, causing damage to the device

• Repeated cleaning action may cause kinks in the brush handle, which lead to damage of the lumen walls

Brush SelectionOne Size Does Not Fit All

Feature Consideration RiskBrush Tip Brush tip

Fan tips are great for close ended channels

Acrylic and standard tips are best with open ended channels

• Not all tip styles clean the same way and could damage lumens and devices

• Ends of closed-ended lumens pose a cleaning challenge as dirt is difficult to reach and can become caked onto surface

Bristle Area Length

Amount of bristle area is proportionate to size of device being cleaned

• Too long of an area may result in bristles extending out of channel during cleaning motion, resulting in splatter spray from exposed bristles

• Too short of an area may not provide efficient cleaning and result in loss of time

Brush SelectionOne Size Does Not Fit All

Feature Consideration RiskBristle Material Bristle material should be

suitable for the material of the device being cleaned

Abrasiveness of bristle material should be appropriate to the condition of the device being cleaned

Compatibility & performance of bristle material with cleaning agents

• Harder bristle materials could damage the surface of the instrument or device

• Soft bristle material will not provide abrasive scrubbing action for difficult to remove soils

• Cleaning agents and chemicals can have different effects on the various bristle materials, causing them to breakdown, shed or otherwise impact the ability to clean effectively

Brush SelectionOne Size Does Not Fit All

Feature Consideration RiskDevice Being Cleaned

Brush recommendation from device manufacturer’s IFU

How soiled is the device

Type of procedure device was used in

• Device manufacture has validated cleaning instructions with a specific type or size of brush other than what is available

• Damage to devices and ineffective cleaning

• More soiled devices require more rigorous cleaning applications so more aggressive brushes may be required

• Reuse of brushes after use on some types of instrument sets may increase risk of patient harm

Disposable vs. Reusable vs. Reposable

Disposable Intended for one-time use (i.e. one case/set)

Reusable Can be reused after cleaning and decontamination

Reposable Handles are reusable but the bristles are single use;

combination of disposable and reusable

Safest & easiest way to minimize cross-contamination

Expensive to replace brushes so often

Cost effective & reduces waste Increased risk of cross-contamination

Least amount of waste Requires more time for cleaning and replacing;Could disassemble during use

Cleaning of Reusable Brushes

“Brushes must be cleaned and disinfected/sterilized…Prompt cleaning of brushes and cleaning tools reduces the number of or eliminates microorganisms that create biofilms.”

IAHCSMM Central Service Technical Manual, Seventh Edition, pg. 142

“Reusable brushes should be disinfected or sterilized at least daily. Disposable cleaning tools should be discarded after use.”

ANSI/AAMI ST79:2010, section 7.5.6, pg. 59

“Brushes used for decontamination must themselves be cleaned and disinfected or sterilized… Prompt cleaning of brushes and other cleaning implements reduces or eliminates biofilm-forming microorganisms and thus minimizes the formation of biofilm.”

ANSI/AAMI ST79:2010, section 7.5.6, pg. 59

“Reusable brushes should be cleaned and decontaminated at least daily or when heavily soiled.”

AST Recommended Standards of Practice for the Decontamination of Surgical Instruments, pg. 5

Cleaning of Reusable Brushes

During use: Clean in detergent with a soft bristle brush each time it emerges from the channel or

lumen; repeat until the brush emerges free of soil

This prevents reintroduction of soil back into the lumen

After use: Rinse gross soils from the brush in a deep sink

This prevents the spraying of soils into the air and onto the user

Use an instrument detergent or enzymatic cleaner in a washer disinfector, ultrasonic cleaner or by manually agitating the bristles under water; repeat until bristles appear free of soil

Type of cleaner depends on types of soil the brush came in contact with during cleaning. Ineffective cleaning of brushes increases disinfection failures and cross-contamination.

Cleaning of Reusable Brushes

After cleaning: Cleaned brushes may be thermally disinfected in the automated washer disinfection stage or with

liquid chemical sterilants

Check with disinfectant manufacturer for compatibility concerns with brush materials

Reusable scope brushes should be high-level disinfected or sterilized after EVERY use on a single scope

Follow the brush manufacturer’s IFU for HLD and sterilization

Sterilization: Always check with the brush manufacturer before sterilizing--can brushes be sterilized after use

or only prior to initial use?

Providing that brushes are clean enough to be sterilized

FUN FACT

Q: Your toothbrush has an average of 10 million germs on it. Therefore you should sterilize your toothbrush weekly to prevent the growth of bacteria such as E.coli, staphylococci, streptococcus and candida.

True or False?

A: False!The ADA recommends rinsing brushes thoroughly after use and allow to air-dry; do not share or let family brushes touch one another; and replace every three to four months or sooner if bristles are worn or splayed.

From the March 2007 issue of O, The Oprah Magazine

Inspecting BrushesHow Do I Know When to Replace?

Inspect brushes for: Wear, fraying or damaged bristles Kinks or bends in the brush handle Residual organic soil

Brush SelectionRisk Summary

Risks associated with improper brush use include:

Ineffective removal of biofilms resulting in patient harm Damage to device Damage to the brush resulting in broken bristles or stems

being left in device Additional time required for re-cleaning

Final Thoughts

“I am only one, but I am still one;

I cannot do everything, but I can do something;

and because I cannot do everything,

I will not refuse to do the something that I can do.”- Edward Everett Hale

(1822 – 1909)

Keep Educating Yourself!

Sources

http://aharesourcecenter.wordpress.com/tag/hospital-acquired-infections-statistics/

http://www.cdc.gov/nhsn/dataStat.html

http://www.cdc.gov/hai/pdfs/stateplans/SIR_05_25_2010.pdf

http://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/overview/deadly-infections-hospitals-can-lower-the-danger.htm

http://www.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs/NHSN_funding_One_Pager_Final.pdf

http://www.rms-foundation.ch/fileadmin/user_upload/pdf/dienstleistungen/ASTM_workshop_on_cleanliness.pdf

Contact Information

Sarah Auel 952-288-2246 Direct

Sarah.Auel@KeySurgical.comKey Surgical, Inc.

800-541-7995info@keysurgical.com